Provider Demographics
NPI:1932150943
Name:RUSSELLVILLE HOLDINGS LLC
Entity Type:Organization
Organization Name:RUSSELLVILLE HOLDINGS LLC
Other - Org Name:VALLEY HEALTH SERVICES OF HECTOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:TERRANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:DILLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-596-7220
Mailing Address - Street 1:11720 SR 27
Mailing Address - Street 2:
Mailing Address - City:HECTOR
Mailing Address - State:AR
Mailing Address - Zip Code:72843-8712
Mailing Address - Country:US
Mailing Address - Phone:479-968-2841
Mailing Address - Fax:479-968-8189
Practice Address - Street 1:11720 SR 27
Practice Address - Street 2:
Practice Address - City:HECTOR
Practice Address - State:AR
Practice Address - Zip Code:72843-8712
Practice Address - Country:US
Practice Address - Phone:479-284-5001
Practice Address - Fax:479-284-4210
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RUSSELLVILLE HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-14
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4192261QR1300X
ARA001233363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR182331729Medicaid
AR182331729Medicaid
AR5GB57Medicare PIN